Planes barely miss worksite in Melbourne Airport close calls
The Australian Transport Safety Bureau has warned that two disasters at Melbourne Airport in 2023 show how quickly routine flights can become dangerous when runway changes are not fully understood.
On separate nights in September 2023, a Malaysia Airlines A330 carrying 247 passengers and a Bamboo Airways 787 carrying 212 passengers took off from a runway that was temporarily shortened due to resurfacing works.
Both aircraft passed only a few meters (7 meters for the Malaysia Airlines flight and only 4.5 meters for the Bamboo Airways flight) over an active work area.
“The first incident involving Malaysian Airlines occurred on 7 September 2023. The second occurred on 18 September 2023, involving Vietnam’s Bamboo Airways,” the ATSB report said.
“Staff were in the work area at the time of both incidents but neither was physically injured.
“A worker reported a stress-related injury due to the proximity of the Bamboo Airways aircraft to their vehicles.”
The investigation revealed that the flight crews of both aircraft did not realize that the length of the runway had decreased as they prepared for takeoff.
Instead, they assumed the entire runway was available, leaving less thrust than needed to safely clear the shortened strip.
“Factors such as expectations, workload and time pressures affected the effectiveness of the crew’s review of the flight information provided in various ways, such that critical information regarding the significantly reduced runway length was not detected,” the report said.
ATSB chief commissioner Angus Mitchell described the incidents as “very serious”.
“An aircraft taking off is one of the most critical stages of flight; anything that can go wrong with an aircraft taking off can have potentially very serious consequences,” Mr Mitchell said.
“Given the potentially catastrophic consequences of a loaded and fully fueled aircraft crashing into a work site during takeoff, additional layers of defense are necessary.”
Procedural weaknesses were also noted in the report.
Although flight administrators had taken the shortened runway into account in their calculations, they were unable to highlight the change in flight crews, and a crew member did not confirm receipt of the automatic terminal information service notification.
The ATSB said both airlines had since updated their internal guidance and procedures, and Airservices Australia, in consultation with the Civil Aviation Safety Authority, had proposed changes to how air traffic controllers communicate basic runway information.
Mr Mitchell said safety reforms were ongoing both domestically and internationally, including improved signage and air traffic control protocols.
He called on the International Civil Aviation Organization to review procedures for warning crews of temporary runway changes.
“Despite the presentation of the relevant NOTAM (Notice to Airmen) in flight briefing packages, neither flight crew detected that the runway had been significantly shortened,” he said.
